Is your clinic prepared for the next natural disaster?

By Amy Coburn, MD, Hilary A. Beaver, MD, and Andrew G. Lee, MD, Blanton Eye Institute/Houston Methodist Hospital

When natural disasters strike, ophthalmologists can play a critical role in recovery through disaster response plans that maintain and restore clinic and hospital operations and provide outreach to the community.

On Aug. 25, 2017, Hurricane Harvey made landfall in Texas as a Category 4 storm, causing billions in property damage, massive power outages, and 88 deaths. In our home town of Houston, 60 inches of rain fell over a period of less than a week, submerging 440 square miles-more than 30% of Harris County. Thousands of Houstonians were rescued by boat, helicopter, and emergency vehicles, and more than 35,000 evacuees sought refuge in more than 250 shelters across the city.

As road access to healthcare facilities was cut off, thousands of evacuees lost glasses and eye medications in the floodwaters, while others suffered eye injuries and disease.

Despites severe challenges, the Houston Methodist Hospital system maintained continuous operation at each of our eight hospitals, including our flagship 907-bed teaching hospital in the Texas Medical Center. Within four business days, the Houston Methodist Physician Organization was back online and delivered care to our typical daily census of 4,000 ambulatory patients. The surgery center was able to accept emergency eye cases from other flood-damaged sites, including an open globe contaminated with flood water, and removal of a radioactive plaque.

The Blanton Eye Institute at Houston Methodist Hospital also re-opened to treat emergent problems. Although more than 15% of the Houston Methodist workforce was affected by the storm through the loss of their home, car, or  a family member, the employees, physicians, and staff of the hospital pulled together to get the hospital and clinics back in service.¹

Five key success factors were identified by our hospital administration in disaster response planning:

1) Disaster infrastructure

2) Resilient culture,

3) Technological developments enabling constant communication,

4) Operational preparedness of staff, and

5) Care coordination.

These success factors are described as a checklist.¹

These same factors are shared in the Houston Regional Ophthalmic Disaster Response Plan developed by Prevent Blindness Texas and the Houston Ophthalmological Society in collaboration with the University of Houston College of Optometry based on our experience treating 3,000 eye patients in the Hurricane Katrina shelters in 2005.

The DRP contains protocols for various disaster scenarios including flooding, hurricanes, tornados, industrial accidents, and mass casualties. It is comprised of:

-partner agreement networks of ophthalmologists, optometrists, opticians, screeners, industry representatives, local government agencies, medical societies, teaching institutions, and volunteers

-mission statements

-communication and transportation plans

-credentialing

-staffing by worker skill set

-equipment setup

-supply needs 

-clinic flow

-medical records

-legal waivers

-delivery of eye care

-triage protocols

Hilary A. Beaver, MD, outside the Red Cross Shelter at the George R. Brown Convention Center which housed almost 10,000 evacuees after Hurricane Harvey. (Photo courtesy of Hiliary A. Beaver, MD)While many Hurricane Harvey victims evacuated to hotels or to undamaged host homes, the majority of evacuees were quickly consolidated into two main shelters at the George R. Brown Convention Center and the NRG football stadium complex.

Ambulatory medical clinics and a 250-bed onsite hospital staffed by the U.S. Department of Health and Human Services were established for victims in desperate need of life-maintaining medical services, such as dialysis and oxygen, and treatment for a wide range of diseases including infection, diabetes, hypertension, and mental illness.

Problems as simple as lost glasses made thousands of evacuees functionally disabled. The shelter also served chronically homeless Houstonians, many of whom had severe undiagnosed or untreated eye disease. Our mission was to restore and preserve functional vision in order for people to re-establish their lives. 

Amina Malik MD mans one of the slit lamps at the George R. Brown Convention Center makeshift eye clinic. (Photo courtesy of Hiliary A. Beaver, MD)The DRP pre-planning allowed us to provide emergency eye care as soon as the general clinics opened (infections, angle-closure glaucoma, postops, etc.) and rapidly ramp up to provide full eye services including 5 lanes for refraction, more than 2,000 new frames for custom glasses fitting, slit lamps, auto refractors, tonometers, and indirect ophthalmoscopes.

Shelter eye clinics operated seven days a week through Sept. 20. Mobile eye vans from Envolve and VSP also brought outstanding optometric care with the advantages of convenient setup, secure control of equipment, and the flexibility to move where needed. Staffing was organized online with Signup Genius in four-hour blocks, each containing workers with complementary skill sets. 

Members of the Houston Ophthalmological Society, volunteers from private practice, and all of our academic medical center partners participated (University of Texas Medical Branch, University of Texas Houston, University of Houston College of Optometry, Texas A and M College of Medicine, and Baylor College of Medicine). Ophthalmologists from San Antonio, and volunteers from as far as Philadelphia and Los Angeles came to help. Prevent Blindness Texas was the key screening partner. By coordinating with the Harrris County Hospital District and area optometrists and ophthalmologists, each patient was provided with a medical home for extended care outside the shelter.

The eye clinics provided examinations for 1,649 patients onsite. Glaucoma and postoperative patients received a 3-month supply of drops. More than 1,000 patients triaged as low risk were given readers with a voucher for offsite complete eye examination, or a voucher for examination and glasses.

The most prevalent problem was uncorrected refractive error. We dispensed more than 1,500 pairs of free prescription spectacles, thanks to generous donations from industry partners (VSP, Envision, Safety Rx, Essilor Foundation, Zeiss, Walmart, Eyes of Faith, Houston Eye Associates, Mann Eye Clinic, Berkeley Eye Clinic, Davis Vision), and the outstanding efforts of the optometry and optician teams.

The ophthalmic diagnoses show the wide range of problems encountered, most of which the core medical team running the clinics could not diagnose or treat. 

• Glaucoma/ glaucoma suspect/ acute angle closure/neovascular glaucoma

• Cataract 

• High myopia and hyperopia: up to -18 D

• Keratoconus

• Diabetic retinopathy/HTN retinopathy

• Tractional retinal detachment/rhegmatogenous RD

• Keratitis

• Preseptal cellulitis; conjunctivitis; hordeolum

• Anterior ischemic optic neuropathy

• Papilledema

• Macular degeneration

• Amblyopia; strabismus

• Corneal abrasion; foreign body  

We are continuing to support the community outside the shelters with resources for examinations and glasses through our collaborative network.

Responding to natural disasters-including flooding-requires adequate preparation before, quick action during, and great flexibility in response to rapidly changing circumstances.

Pre-planning can mitigate the damage to property and people, and ophthalmologists can provide unique and important help to victims and first responders in the effort of recovery. We hope that the key success factors of our experience might be of some value to other communities facing similar catastrophic events in the future.

References

1. Robert A. Phillips, MD, PhD, FACC, Roberta L. Schwartz, PhD, MHS, William F. McKeon, MS & Marc L. Boom, MD, MBA, FACP. Lessons in Leadership: How the World’s Largest Medical Center Braced for Hurricane Harvey. NEJM Catalyst. https://catalyst.nejm.org/lessons-leadership-texas-medical-center-hurricane-harvey/. Last accessed on Oct. 26, 2017.

2. Burling-Phillips. Facing the next disaster: Preparedness for the ophthalmologist. EyeNet. July/August 2008.

3. Coburn, A. Eye care after catastrophe: How we organized eye care for thousands of evacuees: Hurricane Katrina: Practice Perfect, EyeNet. Nov/Dec 2005, p. 47-48.

4. Coburn A, Hubbard J. Houston Regional Eye Care Disaster Response Plan: www.hosmd.org; www.preventblindnesstexas.org. 2007.